2017 Exchange Requirements: Two Steps Forward, One Step Back

Washington, DC (March 1, 2016) – The National Health Council (NHC), as the united voice for people with chronic conditions, described the 2017 Notice of Benefit and Payment Parameters (NBPP) issued by the Centers for Medicare and Medicaid (CMS) as taking two steps forward to enhance the health insurance marketplace, but a big step back.

“We are very pleased to see many patient-centered proposals in the draft NBPP,” said NHC Chief Executive Officer Marc Boutin. “However, ground-breaking opportunities to enhance the delivery of care were dropped from the final rule.”

In its December 2015 comment letter on the draft NBPP, the NHC urged CMS to require plans to count cost sharing for services by an out-of-network provider in an in-network setting towards the enrollee’s maximum out-of pocket limit. CMS is delaying until 2018 action to address this issue. “No patient should receive a ‘surprise bill’ because of a hospital or clinic contractual arrangement that is outside the person’s control,” Boutin said. “But that will continue be a possibility until CMS takes action.”

Likewise, proposed requirements to define time and distance standards for provider networks were not included in the final NBPP. “To tell a person with a chronic condition who buys coverage through a state exchange to wait months to see a specialist or drive hundreds of miles to receive care is to commit that patient to unacceptable hardship – both economically and physically,” said Boutin.

The NHC also expressed its disappointment that CMS has deferred its decision on expanding the use of patient-assistance programs (PAPs). “It is mindboggling that non-profit charities cannot help people in need pay for health insurance,” said Boutin. “We have repeatedly requested clarity on this issue and were very hopeful that we would finally have resolution in this rulemaking. We will continue to push for a commonsense decision.”

Finally, the NHC was pleased to see that the NBPP establishes optional standardized insurance plans. “Standardized plans are structured and presented in ways that make it easier for people to compare options,” explained Boutin. “However, we remain concerned about the high levels of cost-sharing contained in the proposed standard options. The NHC hopes to work with CMS to modify this, and we are grateful that standardized plans are optional until we can sufficiently address this issue.”

The NHC will be reviewing the more than 500-page NBPP in the coming days, in particular to see if the document details guidelines for monitoring and targeting condition-specific discrimination in the marketplace, such as through drug-tiering or the lack of a strong exceptions-and-appeals process.

“This Administration has been a leader in expanding access to health care for millions of Americans,” Boutin said. “The patient advocacy community will not let up on its united effort to enhance the insurance marketplace to ensure it meets the needs of people with chronic diseases and disabilities.”

Founded in 1920, the National Health Council (NHC) is the only organization that brings together all segments of the health community to provide a united voice for the more than 133 million people with chronic diseases and disabilities and their family caregivers. Made up of more than 100 national health-related organizations and businesses, the NHC's core membership includes the nation’s leading patient advocacy organizations, which control its governance and policy-making process. Other members include professional and membership associations, nonprofit organizations with an interest in health, and representatives from the pharmaceutical, generic drug, insurance, medical device, and biotechnology industries.